Staying Healthy and Reducing Transmission

"Me, I try to tell the man that, 'In this house we have been found with this problem. We should accept it. I should not point a finger at you. You, too, should not point a finger at me. Just buy your protection.' And so, little by little what he does now is different from what he did in the past." --Malawi woman living with HIV (Mkandawire-Valhmu and Stephens, 2010: 691)Successfully treated people living with HIV have a normal life expectancy (Sabin, 2013 cited in Justice and Falutz, 2014; Maman et al., 2012a). "There are many things that people living with HIV need to stay healthy: emotional, mental, physical and some might even say spiritual support as well as good nutrition and access to services and medication all of which enhances life and life expectancy" (Dilmitis, 2015).

Given the results of the START study (NIH, 2015), the most important step for staying healthy and reducing transmission is provision of ART and adherence support as soon as a person living with HIV is ready to adhere to ART for the rest of his/her life. Being virally suppressed on effective ART both improves the health of the person living with HIV as well as significantly reduces the possibility of HIV transmission to any sexual partners. However, scaling up ARVS and viral load monitoring for everyone around the world who has tested HIV-positive will remain a global challenge. For people living with HIV who are not virally suppressed, sexual risk reduction is important to stay healthy by reducing exposure to sexually transmitted infections that can accelerate HIV disease progression and by reducing exposure to drug-resistant strains of the virus. It's also an important step to reduce transmission to new HIV-negative partners (Brown and DiClemente, 2011).

Risk Reduction is Necessary During the Acute Stage When HIV is Highly Transmissible

Acute HIV infection, lasting weeks or months, may account for a substantial proportion of HIV-1 transmission worldwide. Acute infection is a highly infectious stage usually lasting between 7 and 21 days occurring immediately following HIV infection (Cohen et al., 2011b), with highly elevated transmission for up to four months following seroconversion (Powers et al., 2011). While some have argued that acute infection is only responsible for a small percent of new infections (Williams et al., 2011b), others have argued that acute infection may lead to efficient transmission chains (Delva and Abdool Karim, 2014; Cohen et al., 2012a; Powers et al., 2014). Currently no guidelines exist for prevention of forward transmission of acute infection (Corneli et al., 2014) and a randomized controlled intervention designed to slow onward transmission did not increase retention in care, although qualitative data found that people living with HIV in the intervention stated that they knew the importance of using condoms and appreciated additional counseling (Corneli et al., 2014). [See also Partner Reduction]

Studies have shown that the efficiency of HIV transmission is directly proportional to the viral load in the transmitting individual (Blaser et al., 2014), i.e., the higher the viral load, the easier it is to transmit HIV. Yet it is difficult, if not impossible, "to quantify risks with an appropriate degree of accuracy for any specific individual in the 'real-world'" in terms of risks for HIV transmission (Gerberry and Blower, 2011: 1120).

Acute HIV infection (or seroconversion phase) progresses into a state of chronic HIV infection that can remain relatively constant for years. This period is associated with a much lower risk of transmission compared with that of acute HIV infection, but because this period can last a median duration of eight years, the cumulative risk of transmission during these eight years can be substantial (Granich et al., 2009). Best practice for the clinical management of acute HIV infection is still under investigation (Bell et al., 2010; Hogan et al., 2012), but a study of 468 people living with HIV in the United States demonstrated that ART initiation within the first four months of infection led to CD4 counts up to 900 cells/lor more seen in 64% of those who initiated ART in the first four months of infection, and in only 34% of those that initiated ART after more than four months of infection (Le et al., 2013). Recent studies have found that early ART limits the persistence of the HIV reservoir and replication of HIV (Ananworanich, 2014).

Stigma and Gender Norms Can Make Efforts to Reduce Transmission Difficult for Women and Men

Non-judgmental, non-stigmatizing interventions are urgently needed for those living with HIV who are not virally suppressed to reduce HIV transmission to sexual partners (Collins et al., 2008). Interventions both within the health sector and outside the health sector, such as transforming norms, reducing violence against women, and revising laws that criminalize non-disclosure of HIV (Groves et al., 2012), need to be implemented in order to support people to live longer and healthy lives, and practice safer sexual behaviors once someone knows his/her positive serostatus. [See also Strengthening the Enabling Environment] "Despite the gain and progress in access to treatment an HIV-positive diagnosis is still seen by many as a death sentence" (Dilmitis, 2014: 7). Women living with HIV suffer from high rates of violence (Kendall et al., 2012; One in Nine Campaign, 2012; Osinde at al., 2011; Aryal et al., 2012) which can create challenges in accessing ART and adherence. [See also Addressing Violence Against Women]

"My baby's father said that if he...(got) HIV, I would be the one to blame...he would kill me." --Women living with HIV who did not disclose her serostatus to her sexual partner (Groves et al., 2012: 802) Some serodiscordant couples identify fear of transmission as a primary concern in their relationships or fear the impact that disclosure will have on the HIV-negative partner (Ananworanich, 2014; Talley and Bettencourt, 2010; Chen et al., 2011; Kelley et al., 2011). Women particularly fear the reaction of male partners if they access ART and they sometimes hide their status and even their ART medication (Machera, 2009). A study in South Africa found that among 413 men living with HIV and 641 women living with HIV, stigma and discrimination was associated with non-disclosure and that non-disclosure was associated with HIV transmission risk behaviors (Simbayi et al., 2007).

"Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other" (Bott and Obermeyer, 2013: S5). At least 63 countries have HIV-specific criminal statutes (Dilmitis, 2014) and therefore people can be prosecuted for transmitting HIV, making disclosure and adherence challenging. In some countries, women who know their status fear being sued by their partners under laws that criminalize transmission of HIV (Hsieh, 2013).

Criminalization of transmission and nondisclosure undermines rights while disserving public health, but gender issues are key to HIV disclosure (Bott and Obermeyer, 2013). [See Advancing Human Rights and Access to Justice for Women and Girls] Because women are tested for HIV at much higher rates than men (many countries have a policy of mandatory testing for pregnant women), any approach that blames women living with HIV for not disclosing their status will disproportionately burden women. Health care systems that are often overwhelmed do not provide appropriate psychcosocial support for pregnant women who discover their HIV-positive status through this kind of testing. Where male partners have been unwilling to get tested for HIV, some women living with HIV did not feel an obligation to disclose their positive serostatus (Groves et al., 2012). Women "reflected upon the fact that men seemed unwilling to test but preferred to blame their female partners" (MacGregor and Mills, 2011: 4). In some cases, women are significantly less likely to know their partners status than men (McGrath et al., 2013). And one study of women living with HIV in South Africa found that consistent condom use was not correlated with disclosure to either HIV-negative or HIV-positive male partners (Onoya et al., 2011). For women living with HIV, "it is ultimately the decision of the man to either use a male condom or not," (Onoya et al., 2011: 1218), with gender norms on sexuality key to male use of condoms. Some evaluated interventions exist regarding womens use of female condoms in the absence of male condom use. However, "limited access to female condoms and substantially higher costs have limited uptake and use of female condoms" (Abdool Karim et al., 2010a: S125) thus limiting an opportunity to reduce HIV infection through a woman-initiated prevention method. [See also Strengthening the Enabling Environment andMale and Female Condom Use]

Fear of Disclosure Impacts Transmission Reduction Efforts

Disclosure is not a one-time event but a process calling for careful consideration as to whom to disclose, when and reasons for disclosing. A study in Zimbabwe of 200 women living with HIV on ART found that 96.5% disclosed to at least one person, most frequently their sister (Patel et al., 2012). Both women and men need to learn how to negotiate safe sex prior to disclosure, knowing when to disclose and how to disclose. Given that there is no global guidance on disclosing - technicalities of why, how and when to disclose is where communities of women living with HIV become essential in providing this kind of peer support. [See Adherence and Support] Women in one study noted that once they disclosed, no man had stayed with them (MacGregor and Mills, 2011). In another study in Uganda, "the need to provide for children was a particularly strong motivation for women to avoid disclosure" (Allen et al., 2011: 539), as men abandoned or abused partners who disclosed or requested condom use. One cross sectional survey in Cameroon found that women living with HIV who were not financially dependent on their male partners were much more likely to have used condoms (Loubiere et al., 2009), suggesting the importance of a strong supportive enabling environment. [See Strengthening the Enabling Environment]

A study in South Africa found that, for men, disclosure undermined men's sense of masculinity and that health-seeking behavior portrayed them as weak and dependent, as well as subject to control by health care providers (Mfecane, 2012). "Men believed that 'real men' deal with personal problems on their own, instead of asking help from other people" (Mfecane, 2012: S115). However, once on ART, men's health and appearance improved and they felt publicly able to share their HIV-positive serostatus, which in turn won them support, approval and admiration, becoming role models for breaking the secrecy and stigma surrounding HIV (Mfecane, 2012). Other studies found that men were particularly critical of serodiscordant couple interventions, as couples counseling puts "the man on trial." As one man put it: "It is as if you are before a court, as you know women can get authority over the man when other people are there...So your wife may ask you how the disease came about. So you have to reveal the extra affairs." (Siu et al., 2013: 48). Couple testing must be implemented in a way that addresses gender imbalances and violent relationships. Providing sex-segregated counseling may also be effective (Jones et al., 2014).

Safer Conception Information is Needed for Those Who Desire Pregnancy

"People living with HIV have feelings...and marriage is a right to everyone, whether HIV positive or not." --19-year-old woman in Zambia, (Mburu et al., 2013: 178)Among people living with HIV who are not virally suppressed, HIV transmission can occur in the attempt to become pregnant. In most low- and middle-income countries, little information is available to couples on safer conception. "In the absence of artificial insemination technologies, effectively unavailable in most low- or low-to-middle income countries, conception requires unprotected sexual intercourse; this means risk of either HIV transmission (in serodiscordant couples) or HIV super-infection (in couples where both couples are positive" London et al., 2008: 14). When the person living with HIV is virally suppressed, the chances of transmission are dramatically reduced [See also Safe Motherhood and Prevention of Vertical Transmission ]

Among those living with HIV and not virally suppressed, superinfection can become an additional health problem. Superinfection is when a person gets infected with different strains of HIV, increasing the risk of drug resistance to ARVs. A study in Uganda found that polygamous relationships among HIV-positive partners results in multiple infections, i.e., superinfection (Ssemwanga et al., 2011). One study found that among 20,220 people in the study in Uganda in a general heterosexual population, rates of superinfection were substantial (Redd et al., 2012) and another study detected superinfection among Kenyan women (Ronen et al., 2013) but found that HIV infection provides partial protection from subsequent infection, with susceptibility to superinfection possibly decreasing over time.

The Relationship Between HIV and Other STIs is Complicated

Among those living with HIV who are not virally suppressed, acquiring STIs can accelerate HIV disease progression (White et al., 2006 cited in Brown and DiClemente, 2011). STIs also increase the risks of HIV transmission (Ward and Ronn, 2010 cited in Brown and DiClemente, 2011). Infectiousness is high in people living with HIV who have a concurrent STI (Brown et al., 2011a). Women living with HIV have higher rates of the STI Trichomonas vaginalis (TV), the second most common STI worldwide, with a seven-day treatment, rather than single-dose therapy, recommended (Lazenby, 2012). A study of 3,297 African sero-discordant couples with 86 linked HIV transmissions found that STIs such as Herpes Simplex Virus-2 (HSV-2), genital ulcers, Trichomonas vaginalis, vaginitis and cervicitis among those who were HIV-negative increased risk of HIV acquisition, even after adjusting for viral load of the person living with HIV (Hughes et al., 2012). The ongoing challenge of treatment for STIs continues to be diagnostic, as well as treating the right infection with the right medication at the right time (Cohen, 2012).[See Treating Sexually Transmitted Infections (STIs)]

STIs in people living with HIV may be associated with a faster progression to death. A study between 2001 and 2009 with 303 women living with HIV with 1,408 person-years in Uganda and Zimbabwe found that STI symptoms were associated with faster disease progression (Morrison et al., 2011). Women living with HIV also have increased risks for certain STIs, such as genital ulcer disease, even after initiation of antiretroviral therapy; one study found an increased risk of Trichomonas vaginalis (Mavedzenge et al., 2010).

Conversely, HIV treatment can benefit certain STI outcomes. A study found that people on ARVs with syphilis are less likely to have neurosyphilis and respond better to neurosyphilis treatment (Marra et al., 2012). Among entirely or predominantly ART-nave adults, a systematic review found that treating STIs reduced HIV viral load (Modjarrad and Vermund, 2010). Questions have been raised about whether Herpes Simplex-2 infection, in particular, enables HIV transmission, though recent observational data found no association between HIV transmission with HSV-2. Clinical trials found no effect of HSV-2 suppression on HIV acquisition and HIV transmission in HIV discordant couples (Celum et al., 2010).

Randomized evaluations of different behavioral intervention models, including clinician-initiated communication are needed (Bunnell et al., 2006b). "When discussions of ongoing STD-related risk behavior do occur, they are infrequent and often initiated at the patient's request. At best, the lack of these discussions in HIV-related care settings is unfortunate; at worst, it indirectly contributes to escalating rates of STIs among [people living with HIV] and of new HIV acquisition among others at risk" (Hall and Marrazzo, 2007: 518).

Treatment Can be a Successful Prevention Strategy to Reduce Transmission

The HPTN 052 study has shown that early initiation of antiretroviral therapy (when CD4 counts were between 350 and 550) for the seropositive partner in a discordant relationship resulted in a 96% relative risk reduction of HIV transmission to the seronegative sexual partner (Cohen et al., 2011a). Ten year results presented at the 8th IAS Conference on HIV Pathogenesis, Treatment Prevention Conference in July, 2015 found durable reductions in transmission, noting "throughout our decade-long study with more than 1,600 heterosexual couples, we did not observe HIV transmission when the HIV-infected partners virus was stably suppressed by antiretroviral therapy" (Cohen et al., 2015; NIH, 2015).

WHO's 2013 guidance recommends ART for all people living with HIV, regardless of CD4 count, who have seronegative sexual partners, while noting that advice should be given on safer sex, including condom use (WHO, 2013). But some have criticized this strategy, noting that a person living with HIV is in a discordant relationship any time they have sex with someone of unknown serostatus. Others have noted that sero-concordant couples also deserve treatment. Still others have noted "prioritizing those in stable partnerships for treatment may not be an efficient form of prevention over providing treatment to the general population without prioritization" (Delva et al., 2012).

Furthermore, a study in Kenya found that almost 40% of serodiscordant couples were unwilling to use early treatment for preventive effect (Heffron et al., 2012 cited in Mills et al., 2013). "Increasingly, there has been recognition of the need for services to work with couples, rather than just with the individual partners" (Spino et al., 2010: 4). Some have suggested that it is important to understand population dynamics through modeling. In a recent modeling exercise, sex workers in West and Central Africa were found to have the highest probability of transmission, even in settings where HIV prevalence is low and there is not a concentrated epidemic (Boily et al., 2015). However, no evaluated studies were found that reached sex workers with treatment for their own needs rather than as vectors of transmission, with the exception of one (Mountain et al., 2014). Given the new START data showing that early treatment has health benefits for the person taking ART as well as reducing the likelihood of transmission, countries will need to assess how ART will be scaled up in a way that respects individual choice, understanding and readiness to undertake life long treatment while also reducing population level transmission.

While the study by Cohen et al., 2011a shows the benefit of treatment for reduction of transmission to the HIV-negative partner, it is important to keep this study in context. Condoms as well as treatment were used to prevent transmission, with self-reported 100% condom use correlated with prevention of transmission. There are a number of hurdles in successfully utilizing treatment as a prevention approach. For example, getting all HIV-positive people to know their serostatus before they are symptomatic and while their CD4 counts are above 350 in order to access treatment will be challenging and unlikely to result in universal coverage in the near future (Over, 2011). Also of significance in the study by Cohen et al., 2011a, is that in 28% of the cases, HIV transmission occurred from another partner rather than from the HIV-positive partner on treatment (Cohen et al., 2011a), demonstrating that monogamy cannot be assumed in serodiscordant couples (Chohan et al., 2015). Population-level benefits of ART could be compromised by sub-optimal ART coverage or adherence (Cohen et al., 2012b). The effect of ART in reducing transmission through routes other than heterosexual contact is not definitively known (Cohen et al., 2013), with clinical trials underway (Cohen et al., 2012b). Data from treatment as a prevention strategy comes almost exclusively from vaginal sex with no data for risk of transmission for anal sex, whether for those who are heterosexual or who are MSM (Collins and Geffen, 2014). However, a recent CROI abstract (Grulich et al., 2015) found no risk of transmission among virally suppressed MSM.

But much of transmission is driven by those who are not yet diagnosed with HIV, rather than those who know their sero-status but are not yet on ART (Collins and Geffen, 2014; Phillips, 2015). A study from South Africa found that "a substantial proportion of [individuals living with HIV] remained at risk of transmitting HIV even after starting ART," (Kranzer et al., 2013: 498), with 39.2% of individuals who reported taking ART "with detectable viral load (above 1,500 copies per milliliter), which is known to be associated with a high risk of transmission" (Kranzer et al., 2013: 501). The logistical challenges, however, of getting all who have tested positive globally on ART and virally suppressed remain daunting.

The use of HIV treatment as prevention is emerging as an exciting component of scaled up AIDS programs (WHO, 2013). Additional discussion of the use of treatment as a prevention strategy can be found in Treatment as Prevention.

"At the same time, we should know that treatment scale-up is not an end in itself, and viral suppression does not equal optimal quality of life." --Suzette Moses-Burton, Executive Director of the Global Network of People Living with HIV (UNAIDS, 2015: 267)"Given the dramatic effect of ART on viral load, it is reasonable to consider using treatment of individuals [living with HIV] as a means of preventing HIV transmission" (Dieffenbach and Fauci, 2009: 2380) and recent results "support the use of antiretroviral treatment as a part of a public health strategy to reduce the spread of HIV-1" (Cohen et al., 2011a: 12). However, treatment programming must be linked with prevention (Holmes et al., 2010b) and "an essential question is how a country's health service could maintain antiretroviral therapy in legions of healthy patients with high CD4 cell counts mainly for prevention benefits to partners, when it is not able to initiate and maintain high levels of retention of those with low CD4 counts who need ART for survival" (Padian et al., 2011b: 275). Rapid ART scale up can exacerbate health system constraints with neglect of prevention for both those living with HIV and those who are HIV-negative (Jacobson et al., 2012). [See also Prevention for Women] Treatment as prevention requires lifelong engagement in care (McNairy et al., 2013b), with the danger that those with high viral loads will be lost to follow up and have low rates of adherence. [See Provision and Access and Adherence and Support] Meeting the challenges of scaling up treatment for those with high viral loads will be difficult, and therefore successfully scaling up treatment for those with low viral loads may be unlikely (Mills et al., 2013).

Some researchers have expressed concerns that risk behaviors may increase "due to the feeling of safety that ART provides" (Shafer et al., 2011: 671) and increasing HIV prevention efforts both for those who are HIV-negative and for those who are HIV-positive is necessary (Shafer et al., 2011). Treatment as prevention still faces challenges due to gender norms, multiple partnerships, and other structural and environmental factors. [See Strengthening the Enabling Environment]

The proper use of condoms remains a reliable means of enabling everyone, without knowing the serologic status of their partners, to protect themselves and others during sexual intercourse. UNAIDS also argues that reducing transmission is a "shared responsibility", so that everyone shares the responsibility to avoid HIV (GNP+ and UNAIDS, 2011). But women often struggle to access and negotiate condom use. [See Male and Female Condom Use and Strengthening the Enabling Environment] Guidelines on promoting the health and dignity for people living with HIV with attention to gender equity are available at: (UNAIDS and GNP+, 2013). Some contend that while treatment can provide regular condom users with added safety, "condoms remain the only way to protect oneself against other STIs" (Bourdillon et al., 2008: 11). Some studies have shown that those on treatment are more likely to use condoms (Kennedy et al., 2010b) and other measures to prevent transmission and other studies, mostly from resource-rich settings (Tun et al., 2004 cited in Cohen and Gay, 2010) have shown the opposite. Treatment as a prevention strategy still requires individual action, such as continued adherence. Even in a resource-rich country like the United States, only one-quarter of people living with HIV "have successfully navigated the ART care continuum to achieve an undetectable viral load with ART" (Fauci and Marston, 2014: 496).

"Let me tell you where there is health, there is life. I tried very much to be single but when I couldnt hold on any longer I got someone who was also...on medication." --Women living with HIV in Uganda (Mbonye et al., 2013: 8)The WHO 2013 guidelines recommend that all those living with HIV be enrolled in care prior to ART initiation, with recommended packages including psychosocial counseling and support (WHO, 2013). Individuals need counseling on the relationship between their CD4 count and/or viral load and the risk of transmission both to sexual partners and in pregnancy in a simple, easy to understand format (Ujiji et al., 2010). [See also Meeting the Sexual and Reproductive Health Needs of Women Living With HIV and Safe Motherhood and Prevention of Vertical Transmission ] Condoms can protect partners who may not be fully adherent and/or virally suppressed, as well as preventing STI acquisition. Questions remain about transmission of ART-resistant strains to partners (Anglemyer et al., 2013).